LESSONS LEARNED
Collaboration between State Agencies and NGOs for Prisoner ReEntry
Collaborative Case Management
Dennis Schrantz, Robb Burroughs and Kirt Baab
Definition
Collaborative Case Management (CCM) is the coordinated and strategic use of resources at the case
level to accomplish agreed upon objectives. It is a dynamic process that starts at the time of
sentencing/intake and continues seamlessly through successful reintegration and stabilization in the
community. CCM aims to reduce crime by engaging all partners in a collaborative process that holds
offenders accountable for their behavior and increases offender success.
The Critical Elements of Collaborative Case Management
Starting from the perspective that communities are safer when individuals returning from incarceration
are successfully reintegrated (i.e. do not commit additional crimes, support their families, pay taxes,
etc.), CCM combines the following elements:
 The goal is behavior change: CCM pushes corrections practice beyond concepts of
incapacitation, supervision, and monitoring by seeking to engage returning prisoners in the
process of change. Rather than abandon the use of surveillance, compliance monitoring, and
sanctions for non-compliance, CCM balances these and other important external controls with
effective treatment and strategies to enhance the individual’s internal motivation to change.
 Interventions are individualized and comprehensive: In order to influence behavior change,
CCM first seeks to identify each individual’s level of risk to reoffend, the criminogenic needs
driving the offense behavior, and the internal strengths and external resources available to
support positive change. The results of the assessment process are then used to plan the mix of
treatment, services, and supervision most likely to lead to success by addressing the complex
and multiple needs of offender.
 Returning offenders are partners in the process: Long-term outcomes are enhanced when the
goals and planned activities are meaningful to the offenders themselves. Instead of setting
conditions and monitoring compliance, staff approaches offenders as active participants in
setting and achieving goals. Consequently, offenders are more likely to acknowledge their own
responsibility to seek change.
 Teams are responsible for case planning and management and engage additional stakeholders
as needed: In addition to the offender, multidisciplinary teams are made up of either
institutional or community corrections staff and a mix of treatment providers, workforce
development specialists, community resources, law enforcement, and others based on the
specific needs of each offender. The team frequently reaches out and coordinates services with
other stakeholders, including family, faith-based groups, and other natural supports.
 Transitions are seamless: In order to ensure continuity of key treatment and services, especially
those that start inside the facility and continue in the community, teams managing cases inside
the facility and teams managing cases in the community communicate and coordinate activities.
The primary tool for case-level communication and coordination is the Transition Accountability
Plan (TAP).
Collaborative Case Management Policy and Practice
The elements of CCM can be translated into more specific policy and practice guidelines for improving
reentry outcomes. The numbered headings are the six core activities for implementation of the
collaborative case management model described in Chapter 5 of the TPC Reentry Handbook. Each is
followed with a brief discussion of policy and procedure recommendations that support implementation
of the core activity.
RESOURCES
Report of the Re-Entry
Policy Council: Policy
Statement 8 –
Development of Intake
Procedure
Prisoner Reentry
Initiative Coaching
Packet:
Effective Case
Management
Putting Public Safety
First: 13 Parole
Supervision Strategies
to Enhance Reentry
Outcomes:
Strategy 8 – Assess
Criminogenic Risk and
Need Factors
Report of the Re-Entry
Policy Council:
Policy Statement 5 –
Promoting Systems
Integration and
Coordination
Policy Statement 25 –
Design of Supervision
Strategy
1. Conduct assessments of offenders’ risks, needs, strengths, and environment.
CCM activity should start at the point of intake to the facility with a comprehensive
assessment process. The goal is to build awareness of the personal, situational, and
historical/contextual factors behind each offender’s criminal justice involvement, as well as
his or her strengths that can be accessed to mediate risk. The focus of the assessment
process should be validated measure of risk and criminogenic need but should also include
multiple screenings and further assessment, as indicated, for a full range of personal
history and needs, including but not limited to health, mental health, family relationships,
employment, and housing stability.
Because gathering all of the necessary information will require the use of generalized
risk and need assessments, screenings, and follow-up assessments, facility policy should
define a streamlined process for selecting, administering, and tracking assessments. In
addition, the staff administering assessments should be properly trained and supervised
and use instruments that have been validated.
Although the most extensive and intensive assessment work may take place at the point
of intake, policies and procedures should be in place for reassessment throughout the
entire reentry process. Reassessment allows the team to uncover new or evolving needs
and to track changes in dynamic criminogenic needs following delivery of treatment,
programming, and other interventions.
2. Form, participate in, and lead case management teams that work
collaboratively.
Throughout all three phases of reentry, case planning and management activities are
conducted by an interdisciplinary team called a transition team. The composition of the
transition team and the respective roles of its members will change over time, as the
offender completes goals, identifies new needs, and transitions through the three phases.
Generally, the team should include the offender, prison staff, community supervision staff,
facility and community-based service providers, and family members and/or pro-social
supports. During the institutional phase prison staff may lead the team. During the reentry
Policy Statement 26 –
Implementation of
Supervision Strategy
Prisoner Reentry
Initiative Coaching
Packet:
Engaging in
Collaborative
Partnerships to
Support Reentry
Putting Safety First: 13
Parole Supervision
Strategies to Enhance
Reentry:
Strategy 7 – Engage
Partners to Expand
Intervention Capacities
Report of the Re-Entry
Policy Council:
Policy Statement 9 –
Development of
Programming Plan
Policy Statement 17 –
Advising the Releasing
Authority
Policy Statement 25 –
Design of Supervision
Strategy
Effective Case Planning
Strategies (webinar)
Putting Safety First: 13
Parole Supervision
Strategies to Enhance
Reentry:
Strategy 9 – Develop
and Implement
Supervision Case Plans
that Balance
Surveillance and
Treatment
and community supervision phase parole officers may lead the team. During the
reintegration phase human services agencies or community services providers may lead the
team.
In order to facilitate effective and efficient transition team operation, policies should be
in place to define team composition, member roles and responsibilities, and the content
and process of information sharing between team members. It is also important to ensure
that staff members responsible for case management have the knowledge, skills, and time
to carry out new and likely more intensive activities. Creating adequate staff capacity may
mean removing or reducing prior staff responsibilities that are no longer needed.
Whenever personal information is shared, it is critical to maintain the offenders’ rights
to confidentiality. However, with appropriate consent, information sharing across agency
boundaries is necessary for good assessment and case management. One way to facilitate
the exchange of information between agencies and systems is to share access and even link
information technology systems in use by the respective service systems (i.e. corrections,
mental health, human services, etc.). Again, the technology should include safeguards to
ensure that information identified with a specific individual can only be accessed by
members of the team who have been authorized to view that information.
3. Develop and implement – along with offenders and other partners within both
correctional and other agencies – a transition accountability plan geared directly
to the level of offender risk and criminogenic needs.
The transition accountability plan (TAP) is a concise guide for the offender and case
management team that describes the goals identified for each offender’s successful
transition and the schedule of actions that need to be taken by the offender, prison staff,
releasing authority, community supervision staff, partnering agencies, and others to
achieve those goals. The increased certainty and clarity of goals and activities will motivate
offenders to participate in the case management process and fulfill their responsibilities.
Likewise, the TAP will ensure that all parties are held accountable for timely performance
of their respective responsibilities. The TAP spans the three phases of the transition
process, as well as agency barriers, to ensure continuity of care between the institution and
the community. At a minimum, the TAP should be formally updated at four critical
junctures in the reentry process:

TAP1: The Prison Programming Plan – Completed at intake, the TAP1 includes the
expectations for the prison term that will help inmates prepare for release.

TAP2: The Parole Plan and Reentry Plan – Completed prior to release, the TAP 2
describes the terms, conditions, and expectations about the prisoners release to
communities.

TAP3: The Treatment and Supervision Plan – Completed upon return to the
community, the TAP 4 includes a detailed schedule of the supervision and services
offenders will experience in the community.

TAP4: The Discharge and Aftercare Plan – Completed prior to successful discharge
from parole/probation, the TAP4 describes how the offender will maintain longterm success in the community with the support of community service agencies
and informal prosocial supports.
Figure 3.1 on the next page illustrates the use of the TAP through the points of the
reentry process.
FIGURE 3.1
SPR Framework Transition Accountability Planning (TAP) Flowchart
PHASE 1: GETTING
READY
The Institutional Phase
PHASE 2: GOING HOME
The Transitional Phase
TAP2:
Parole &
Reentry
Plan
TAP1:
Prison
Programming
Plan
Assessment &
Classification
Inmate
Programming
PHASE 3: STAYING
HOME
The Community Phase
Inmate Release
Preparation
TAP3:
Treatment &
Supervision
Plan
Supervision &
Services
Release
Decision
Making
Revocation
Decision Making
Transition Team Meetings (Monthly):
Attended by transitional planners, probation/
parole reps, service providers, offender, and
his/her family
TAP4:
Discharge &
Aftercare
Plan
Discharge &
Aftercare
Transitional Planners: Work with offenders while they are incarcerated preparing them for release and continue to work as partners with
probation and parole for as long as one year after release.
RESOURCES
Report of the Re-Entry
Policy Council:
Policy Statement 14 –
Behaviors and
Attitudes
Policy Statement 27 –
Maintaining Continuity
of Care
Policy Statement 9 –
Development of
Programming Plan (pp.
141 – 153)
Policy Statement 14 –
Behaviors and
Attitudes (pp. 201 –
210)
Policy Statement 26 –
Implementation of
Supervision Strategy
(pp. 358 – 369)
Putting Safety First: 13
Parole Supervision
Strategies to Enhance
Reentry:
Strategy 10 - Involve
Parolees to Enhance
their Engagement in
Assessment,
Case Planning, and
Supervision
Report of the Re-Entry
Policy Council:
Policy Statement 26 –
Implementation of
Supervision Strategy
Policy Statement 29 –
Graduated Responses
Putting Safety First: 13
Parole Supervision
Strategies to Enhance
Reentry:
4. Provide or facilitate access to programs and interventions to address risk and
needs.
In addition to the role members of the transition team will play in delivering direct
services, including assessment, treatment, and motivational enhancement, at various
points, the transition team will also fill a referral and brokerage role. The two
complimentary roles ensure that offenders have access to treatment, programming, and
interventions that will effectively address risk and needs. Interventions should be
consistent with the principles of evidence-based practice.
5. Involve offenders in the case management process and engage them in the
process of change, making efforts to enhance their motivation.
By engaging offenders in the assessment, planning, and case management process, CCM
is more than a means of referring to and tracking participation in various treatment
programs. It is an intervention on its own, complimenting and enhancing the outcomes of
other interventions. The evidence is strong that offenders are more likely to achieve and
sustain desired behavior changes if the goals and process for achieving the goals are
meaningful for them.
One way to build this intrinsic motivation is to involve offenders as the central member
of the transition team when conducting assessment, planning, and progress monitoring. It
is not enough just to ask for his or her feedback from time to time. The team should seek
to build a trusting relationship with the offender through regular and consistent contact,
including both formal meetings and less formal check-ins, such as a conversation during
meal time at the facility or a home visit in the community.
Another, more direct means to enhance motivation, is for members of the transition
team to use communication styles and techniques designed to enhance motivation, such as
Motivational Interviewing (MI), in all of their interactions with the offender. Rather than
impose goals and demand solutions, these approaches employ empathy and specific
communication skills to direct the offender through his or her own exploration of the need
for change and identification of goals and solutions. Integrating MI and other approaches
to enhance motivation into staff-offender interactions requires training and ongoing
coaching for the staff, as well as policies and procedures that establish the value of these
approaches.
6. Review progress and adapt plans accordingly over time, including monitoring
conditions of supervision and responding appropriately to both technical and
criminal violations.
Through the use of formalized assessments, as well as frequent and consistent
communication with the offender, members of the transition team, treatment providers,
family members, and others engaged in the transition process, it is important to assess
progress toward desired changes over time. When progress is slower than expected or
there are indications that the offender is sliding back toward old problematic behavior
patterns, a swift response to identify the problem and adjust the plan accordingly is
needed. Conversely, faster than expected progress, compliance with facility expectations
Strategy 12 –
Incorporate Incentives
and Rewards into the
Supervision Process
Strategy 13 - Employ
Graduated ProblemSolving Responses to
Violations of Parole
Conditions in a Swift
and Certain Manner
and community supervision conditions, and other achievements should be acknowledged
and rewarded, as appropriate, as a means to enhance motivation further.
The transition team’s focus on monitoring and adjusting the transition plan is especially
important in the period immediately following return to the community. Most people
transitioning from the facility environment to the community experience some degree of
anxiety and stress and need an adjustment period. The appearance of problem behaviors,
especially during this adjustment, does not necessarily indicate a return to criminal
behavior. It is important that community supervision officers have the skills to distinguish
between the behaviors that are affiliated with a risk of future transgression and behaviors
that are more likely associated with the adjustment. Regardless of the cause of the
problem behavior and the potential risk it signals, the supervision officer and transition
team should be equipped with a full range of responses, including graduated levels of
sanctions, that can be used to facilitate compliance and encourage success. Ensuring the
community’s safety is the top priority, and returning an individual to incarceration may be
necessary in some cases to protect safety. However, as a default response to all violations,
re-incarceration does little to change behavior patterns and protect safety over the long
term.